Degenerative hip and spine pathologies often co-exist, as Hip-Spine-Syndrome (HSS). Many patients eventually need surgery in both hip (THR) and spine [decompression-spinal-arthrodesis (DSA)]. This case-control study aims to determine whether the presence of a DSA compromised THR outcome and whether outcome of THR is better if performed prior to- (THR-1^st) or after- DSA (THR-2^nd).

This is a single centre, multi-surgeon, retrospective, case-control study. Of the 748 patients that underwent DSA between 2004–15, 43 patients (54 THRs) have also had a 1° THR(s) at our unit and formed the cases. Thirty-two THRs were performed prior to the DSA (THR-1^st) and 22 were done following the DSA (THR-2^nd). Most cases had either 1- (n=3) or 2-level (n=20) DSA. The most common DSA level was L4/5 (n=23). The mean THR-DSA interval was 3.6 years. Controls were patients (n=67) without DSA or previous spinal surgery, that had a THR in our unit over the same study period matched for age, gender and type of THR implanted.

Patient Reported Outcome Measures (PROMs) were obtained using the Oxford-Hip- and Harris-Hip-Scores (OHS/HHS), with the difference between post- and pre-operative scores defined as Δ. Outcome was compared between Cases and Controls and between THR-1^st and THR-2^nd Groups. Outcome measures included complications, revisions, PROMs and cup orientations achieved.

The mean age at THR was 67 years old (SD: 11) and most patients were female (n=82, 68%). The mean cup inclination and anteversion angles were 41° (SD:8) and 21° (SD:8). At a mean follow-up of 6 years, the OHS improved from OHS_pre:16 (SD: 7) to OHS_fu:41 (SD:10) and the HHS improved from HHS_pre:51 (SD:14) to HHS_fu:88 (SD:13).

A greater incidence of complications were seen in the Cases (n=10; ARMD-3, infection-4, loosening-2, dislocation-1) compared to the Controls (n=3; dislocation-2, loosening-1) (p=0.01). Consequently, more THRs required revision in the Cases (n=7) compared to the Controls (n=1) (p=0.01). There were no differences in OHS_pre/OHS_fu/ΔOHS/HHS_pre/HHS_fu/ΔHHS between cases and controls (p=0.1 – 0.9).

There were no difference in complications (7/29 Vs. 3/25; p=0.3), nor revision rates (5/29 Vs. 2/25; p=0.3) between THA-1^st and THA-2^nd Groups. Greater differences in PROMs were detected between the groups. The THA-1^st Group, compared to the THA-2^nd Group had higher OHS_pre (19 Vs 12), HHS_pre (54 Vs 48), OHS_fu (43 Vs 32) and HHS_fu (93 Vs 76), (p=0.001–0.005). However, no statistically significant difference in ΔOHS (24 Vs 17) and ΔHHS (39 Vs 26) were seen between the THA-1^st and THA-2^nd Groups (p=0.1).

Patients with a 1° THR and DSA, had a greater rate complications and revisions compared to a matched control. Overall, no difference in PROMs were seen between Cases and Controls. No significantly increased risk of dislocation was seen in this predominantly 1- and 2-level DSA cohort. The superior PROMs detected in the THA-1^st Group provide evidence that the hip pathology should be addressed 1^st (in cases with 1- or 2-level planned DSA).

Neurogenic claudication is most frequently observed in patients with degenerative lumbar spinal stenosis. We describe a patient with lumbar epidural varices secondary to obstruction of the inferior vena cava by pathological lymph nodes presenting with this syndrome. Following a diagnosis of follicular lymphoma, successful chemotherapy led to the resolution of the varices and the symptoms of neurogenic claudication.

The lumbar epidural venous plexus may have an important role in the pathogenesis of spinal stenosis. Although rare, epidural venous engorgement can induce neurogenic claudication without spinal stenosis. Further investigations should be directed at identifying an underlying cause.

Aim

The purpose of our study was to see what the microbiological epidemiology of our discitis biopsy specimens were. In doing this we could identify if biopsy served a strategic and necessary purpose in the management of this potentially serious pathology.

Objective

Our aim is to assess the use of the cervical nerve root block (CNRB) in the treatment of radicular pain associated with degenerative cervical spine disease and its potential to limit the need for surgical intervention.

Retrospective analysis of radiology reports of conventional MRI in 100 patients with definite spinal stenosis to determine the incidence of reported “foraminal stenosis”.

Prospective study of MRI including T2 coronal and T2 STIR coronal sequences in 57 patients with suspected stenosis. Three surgeons and one radiologist independently compared the diagnoses on conventional and coronal scans.

Patients with suspected spinal stenosis undergoing MRI.

Incidence of “foraminal stenosis” on radiologists' reports.

Diagnoses obtained by different scanning methods.

Retrospective analysis: “foraminal stenosis” called by radiologists in 46% using conventional axial and sagittal sequences.

Prospective study - 57 patients: conventional sequences diagnosed lateral recess stenosis well but also suggested foraminal stenosis in 33%. However, coronal sequences clearly showed no foraminal nerve compression.

In degenerative spondylolisthesis conventional scans suggested foraminal stenosis in 8 of 11 cases. Coronals showed no foraminal stenosis.

Excellent correlation was found in normal spines and in disc herniation. In far lateral disc herniation and isthmic spondylolisthesis, true foraminal stenosis was confirmed by conventional and coronal imaging.

Additional coronal MRI sequences prove that foraminal stenosis is over-diagnosed and is rare in spinal stenosis, but true foraminal nerve compression occurs in isthmic spondylolisthesis and far lateral disc herniation.

Decompression of the lumber spine for spinal stenosis is the most commonly performed spinal surgical procedure in patients over 60 years old. The aims of surgery are to relieve compression of the spinal nerves and retain integrity of the structural elements of the spinal column and its function as a supportive structure. In trying to avoid excessive removal of the posterior supportive structures of the spinal column without compromising full and safe decompression of the spinal nerves, techniques are being developed to reduce bone removal but also allow access to the spinal canal.

One such micro-decompression involves a hemi-laminectomy and lateral recess decompression on the more symptomatic side followed by undercutting the spinous processes and decompressing the opposite side from within the canal aided by the use the operating microscope, a high speed burr and a copper moldable retractor to protect the dura and nerves.

We have reviewed our first 100 consecutive patients who have had a spinal micro-decompression over a period of 5 years. 58 Female and 42 male patients are included in this series. Mean age was 65 years. Patients were assessed by a combination of clinical review and self-assessment questionnaires. After a follow-up period of up to five years (mean 3.5 years) we have seen symptomatic late instability develop in four patients requiring a further surgical procedure in two of these. Symptoms typically developed two years after the original operation following an initial improvement in radicular symptoms and back pain.

This compares favourably with published results for wide decompression where re-operation rates of 18% are reported. We have analysed the cases of delayed instability in more detail to evaluate whether the late deterioration could have been predicted.

Micro-decompression is shown to be safe with few complications and has advantages over wide decompression without compromising safety.

We describe a modified technique of micro-decompression of the lumbar spine involving the use of an operating microscope, a malleable retractor and a high-speed burr, which allows decompression to be performed on both sides of the spine through a unilateral, hemi-laminectomy approach. The first 100 patients to be treated with this technique have been evaluated prospectively using a visual analogue score for sciatica and back pain, the MacNab criteria for patient satisfaction, and functional assessment with the Oswestry Disability Index.

After a period of follow-up from 12 months to six years and four months, sciatica had improved in 90 patients and back pain in 84 patients. Their result was graded as good or excellent by 82 patients according to the MacNab criteria, and 75 patients had subjective improvement in their walking distance. Late instability developed in four patients.

Lumbar micro-decompression has proved to be safe, with few complications. Postoperative instability requiring fusion was uncommon, and less than using traditional approaches in published series.

Decompression of the lumbar spine for spinal stenosis is the most commonly performed spinal surgical procedure in patients over 60 years old. The aims of surgery are to relieve compression of the spinal nerves and retain integrity of the structural elements of the spinal column and its function as a supportive structure.

In trying to avoid excessive removal of the posterior supportive structures of the spinal column without compromising full and safe decompression of the spinal nerves, techniques are being developed to reduce bone removal but also allow access to the spinal canal. One such micro-decompression involves a hemi-lami-nectomy and lateral recess decompression on the more symptomatic side followed by undercutting the spinous process and facet joints and decompressing the opposite side from within the canal aided by the use the operating microscope, a high speed burr and a metal guard to protect the dura and nerves.

Although previous reports exist, as yet, there is no long-term evidence that the theoretical benefits of this “micro-decompression” translate into real clinical improvement in outcome with a reduction in the incidence of post-operative instability in comparison with the bilateral “fir-tree” type of decompression.

We have reviewed our first 100 consecutive patients who have had a spinal micro-decompression carried out by a single spinal surgeon over a period of 5 years. Patients with central or lateral recess stenosis with unilateral or bilateral symptoms were considered for this procedure with 58 female and 42 male patients included in the follow-up series. Mean age was 65 years. Patients were assessed by a combination of clinical review and self-assessment questionnaires. After a follow-up period of up to 5 years (mean 3 years) we have seen symptomatic late instability develop in 4 patients requiring a further surgical procedure in 2 of these. Symptoms typically developed 2 years after the original operation following an initial improvement in radicular symptoms and back pain. This compares favourably with published results for wide decompression where re-operation rates of 18% are reported. We have analysed the cases of delayed instability in more detail to evaluate whether the late deterioration could have been predicted. This has allowed us to clarify the specific indications and contra-indications to the micro-decompression procedure.

Lumbar micro-decompression has proved to be safe with few complications. It would appear that this technique has advantages over wide decompression without compromising safety but it will be important to continue with longer term follow-up of these cases.

Bilateral decompression of spinal stenosis may induce instability which compromises outcome. In an attempt to overcome this problem, bilateral decompression can be carried out through a unilateral approach. The ipsilateral side is decompressed by hemi-laminectomy with undercutting partial facetectomy and the contra-lateral side is treated by careful excavation beneath the spinous processes and laminae with preservation of the laminae, posterior ligament complexes and paraspinal muscles. This is achieved with the aid of an operating microscope or loupe and headlight. Previous reports contain little information about outcome and complications.

We reviewed 30 patients with bilateral spinal stenosis, but without significant spondylolisthesis who were decompressed bilaterally from a unilateral approach by a single surgeon during a calendar year. They represented a third of our annual operations for spinal stenosis. Thirty patients had 45 levels decompressed. Female to male ratio was 2:1 and average age was 66 years. The average duration of preoperative symptoms was 1.6 years. The mean follow up period was 30 weeks (12 weeks to one year).

Assessment was carried out using the Oswestry Disability Index, pre- and post-operative visual analogue pain scores for leg pain and back pain, walking distance and MacNab criteria of patient outcome.

Results: improvement in Oswestry Disability Index, pain scores for sciatica and back pain and improved walking distance. All but one case had good or excellent outcome.

Complications: one dural tear and two cases with temporary dermatomal sensory change.

Whilst the technique is safe, and effective, a longer randomised controlled study is needed to demonstrate any real advantage over traditional approaches.

We describe a method for approaching the lower cervical and upper thoracic spine, the brachial plexus and related vessels. The method involves the elevation of the medial corner of the manubrium, the sternoclavicular joint, and the medial half of the clavicle on a pedicle of the sternomastoid muscle. We have used this exposure in 17 cases with few complications and good results. Its successful performance requires high standards of anaesthesia, surgical technique and postoperative care.

We have reviewed 50 patients at a mean period of 2.7 years after operations to restore elbow flexion lost as a result of traction injuries of the brachial plexus. A variety of operations were used and, in general, patient satisfaction was high. Objectively, however, the power in the transferred muscles was poor; less than half of the patients had a significant improvement in function. Poor control of the shoulder often compromised the result. Latissimus dorsi and triceps transfers proved most reliable, and some Steindler flexorplasties also gave satisfactory results. Pectoralis major transfers were disappointing and we do not recommend their use in women.

Severe traction injuries may damage the brachial plexus at any level from the spinal cord to the axillary outlet. Investigation aims to determine the level of the injury for each of the nerves, trunks or cords, with particular reference to obtaining firm evidence of any intradural (pre-ganglionic) damage. We report the results of computerised axial tomography of the cervical spine in comparison with conventional myelography and with surgical exploration of the plexus. CT scanning with contrast enhancement greatly improves diagnostic accuracy, particularly at C5 and C6 root levels.